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General NPI Number Information
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NPI Number | 1881716405
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Entity Type | Organization
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Legal Business Name | MATA CHIROPRACTIC, INC.
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 01/16/2013
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Provider Practice Location Address
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Address Line | 461 W BADILLO ST
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City | COVINA
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State | CA
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Zip | 91723
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Country | US
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Telephone | 626-966-4469
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Fax | 626-915-8929
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Provider Business Mailing Address
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Address Line | 461 W BADILLO ST
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City | COVINA
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State | CA
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Zip | 91723-1834
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Country | US
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Telephone | 626-966-4469
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Fax | 626-915-8929
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. OLMAN EDWARD MATA
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Credential | DC
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Telephone | 626-966-4469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 22763
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License Number State | CA
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